CPE questionaire

Name

First NameLast Name

Please describe any health concerns you have:

Please List your current medications (dose/prescriber included if possible)

Please list your current supplements (brand/dose included if possible)

Please list your doctors/care team, including our doctors and approximately when you saw them last.

Do you have any allergies?

Any new diagnoses, surgeries or other medical events?

How is your family? Any new family history we should know about?

Please select your Tobacco usage history:

Date

Last Date of Influenza/Flu vaccine

Estimated Date

I cannot recall when I had a flu vaccine.I have not had a flu vaccine.

Last Date of Tetanus vaccine

Estimated Date

Tetanus Vaccine

Date

I cannot recall getting a tetanus vaccine.I have not had a tetanus vaccine.

COVID Vaccine

Date

Last Date of Covid vaccine

Estimated Date

I do not plan to have a covid vaccine.

Covid Vaccine (Most recent, if applicable)

Date

Which COVID Vaccine did you get?

Last Date of HPV vaccine (if applicable)

Estimated Date

HPV Vaccine (If applicable)

Date

I have not had the HPV vaccine.

Last Date of Shingles vaccine (if applicable)

Estimated Date

Shingles Vaccine (If applicable)

Date

I have not had a shingles vaccine.ZostavaxShingrixI don't know.

Pneumonia Vaccine (If applicable)

Date

Last Date of Pneumonia vaccine (if applicable)

Estimated Date

I have not had a pneumonia vaccine.

Last Date of RSV vaccine (if applicable)

Estimated Date

RSV Vaccine (If applicable)

Date

I have not had a RSV vaccine.

Anything regarding vaccines you would like the doctor to know about?

When was your last dental cleaning?

Date

When was your last dental cleaning?

Estimated Date

When was your last eye exam?

Estimated Date

When was your last eye exam?

Date

When was your last dermatology exam (skin check)?

Estimated Date

When was your last dermatology exam (skin check)?

Date

When was your last colonscopy?

Estimated Date

When was your last colonscopy?

Date

When was your last bone density screening?

Estimated Date

When was your last bone density screening?

Date

When was your last well woman exam?

Estimated Date

When was your last well woman exam?

Date

When was your last mammogram?

Estimated Date

When was your last mammogram?

Date

When was your last pap smear?

Estimated Date

When was your last pap smear?

Date

When was your last last period?

Estimated Date

When was the first day of your last period?

Date

How often do you perform self breast/testicular exams?

Things I want to talk to my doctor about:

Please note, per insurance companies and coding compliance, discussing concerns outside of wellness screenings requires us to bill a separate visit. This will incur a copay or bill against your deductible.

Please feel free to attach any documents, labs, imaging that you would like in your medical chart.

Preventative visits are important for your overall health. They help us find problems early, before you have any symptoms. This can prevent more serious health issues down the road. We want to help you understand what a preventative visit covers and what it does not.

Types of preventative services: for lowering health risks:

· Annual physical

· Well-Child exam

· Well-woman exam

Services covered as part of a preventative visit:

· Medical history check

· Physical exam

· Guidance for lowering health risks

· Age-related advice to improve overall health

· Ordering screening tests and immunizations, as needed

Services that are NOT part of a preventative visit:

These are considered a second service and need to be billed separately. In some cases, you may need to make a second appointment.

· Diagnosing, testing or treating a new concern, like a rash, cough, etc.

· Managing existing medical issues like depression, asthma, high blood pressure, etc

· Performing procedures like ear cleaning, removing a skin tag or wart, etc.

· Screenings like hearing, vision, behavioral health, etc.

Your health and wellness are our highest priorities. It’s important to tell us if something is bothering you. Your provider will only recommend care you need.

We look forward to seeing you soon.

Signature

Wellness Check In

How up to date are you with immunizations?

Prevention Self Care